Free Paper Australian Podiatry Conference 2019

A systematic review into the diagnostic accuracy of clinical tests for detecting Posterior Tibial Tendon Dysfunction. (#8)

Stephanie Lubcke 1 , Ryan S Causby 1 , Ian Fulton 1 , Sandy Maranna 1 , Steve Milanese 1
  1. School of Health Sciences, University of South Australia, Adelaide, SA, Australia


Posterior Tibial Tendon Dysfunction (PTTD) is a progressive foot condition caused by overuse or degeneration of the Posterior Tibial Tendon. The condition is seen in orthopaedic, podiatry and physiotherapy clinics.  Diagnosis is attained primarily through clinical tests and occasionally confirmed with MRI or ultrasound.

However, the evidence supporting the clinical tests is not clear.  Thus, to determine the diagnostic accuracy of clinical tests for detecting PTTD in people with medial foot pain and associated symptoms we undertook a systematic review.


Searches of AMED, Medline, Embase, CINAHL, PubMed and Scopus were conducted. Two independent reviewers were involved in study selection and quality appraisal using Covidence and the QUADAS-2 tool, respectively.


The initial database search yielded 813 articles. After title and abstract screening and duplicate removal, 47 studies remained. From these, 42 studies were excluded based on set criteria such as study population, study design, having a suitable index test and language; leaving five studies which had investigated the diagnostic accuracy of clinical tests for PTTD. 

These studies comprised nine clinical tests, including: Unipedal standing balance test, Posterior Tibial Edema Sign, First Metatarsal Rise Sign, Single Leg Heel Raise (SLHR), Double Heel Raise, ‘Too many toes sign’ and Passive and Active muscle testing.  The most common being the SLHR.  Of the included studies, MRI was the reference standard in three studies, surgical exploration in one study and a control group was used in one study instead of a reference standard. Ultrasound was also utilised in two studies as an additional comparison reference standard.

However, all studies reviewed were at risk of bias and had concerns regarding their applicability.

Discussion and Clinical Relevance

This review finds that there is limited evidence of the diagnostic accuracy of clinical tests for PTTD.  A discussion of the findings of the review and the identified clinical tests will be provided, with the aim of providing clinicians with the evidence underpinning tests commonly used in podiatry practice.  Future research should be conducted into this area with a focus on high quality, well-powered studies investigating different clinical tests compared to a gold standard.